1. The Role of Medicare and Medicaid in State and National Health Reform
Diane Rowland, Sc.D.
Executive Vice President,
Henry J. Kaiser Family Foundation
and
Executive Director,
Kaiser Commission on Medicaid and the Uninsured
for
National Congress on the Un and Underinsured
December 12, 2007
Washington, DC

2. Health Insurance Coverage in the U.S., 2006
Total = million
* Medicaid/Other Public includes Medicaid, SCHIP, other state programs, and military-related coverage.
NOTE: Those enrolled in both Medicare and Medicaid (1.8% of total population) are shown as Medicare beneficiaries SOURCE: KCMU/Urban Institute analysis of March 2007 CPS.

3. Uninsured Rates Among the Nonelderly,
by State, NH VT ME WA MT ND MN MA OR NY ID SD WI MI RI WY CT PA IA NJ NE OH NE IN NV IL DE WV UT VA CO MD CA KS MO KY NC DC TN OK SC AR AZ NM GA MS AL TX LA
TWO YEAR POOLED ESTIMATES FOR US RATE AK FL HI
≥ 18% (19 states)
US Average = 18%
13-17% (18 states & DC)
< 13% (13 states)
SOURCE: Urban Institute and KCMU analysis of the March 2006 and 2007 Current Population Survey. Two-year pooled estimates for states and the US ( ).

4. Characteristics of the Uninsured, 2006
Family Work Status
Family Income
Age
Part-Time
Workers
11%
55-64 9%
0-18
20% No
Workers
18%
35-54
32%
Deleted “Data may not total 100% due to rounding.”
19-34
39%
1 or More Full-Time Workers
71%
Total = 46.5 million uninsured
The federal poverty level was $20,614 for a family of four in SOURCE: KCMU/Urban Institute analysis of March 2007 CPS.

5. The Nonelderly Uninsured, by Age and Income Groups, 2006
Other Adults without Children 21%
Total = 46.5 million uninsured
Low-income includes those with family incomes less than 200% of the federal poverty level.
SOURCE: KCMU/Urban Institute analysis of March 2007 CPS.

6. Medicaid Today MEDICAID Health Insurance Coverage
29 million children & 15 million adults in low-income families; 14 million elderly and persons with disabilities
Assistance to Medicare Beneficiaries
7.5 million aged and disabled — 18% of Medicare beneficiaries
Long-Term Care Assistance
1 million nursing home residents; 43% of long-term care services
MEDICAID
Data in boxes may need to be updated—unsure of source.
Support for Health Care System and Safety-net
15% of national health spending
State Capacity for Health Coverage
43% of federal funds to states

7. Medicaid Enrollees and Expenditures by Enrollment Group, 2004
Elderly
10%
DSH 6%
Elderly
26%
Disabled
14%
Adults
26%
Disabled
39%
Children
50%
Adults 12%
Children 17%
Total = 58 million
Total = $274 billion
SOURCE: Urban Institute and Kaiser Commission on Medicaid and the Uninsured estimates based on FY 2004 MSIS and CMS-64 data.

8. Health Insurance Coverage of Low-Income Adults and Children, 2006
Poor
Near-Poor
(<100% Poverty)
( % Poverty)
Children
Poor
Near-Poor
Parents
corrected near poor child data
Adults without Children
Poor
Near-Poor
Medicaid also includes SCHIP and other state programs, Medicare and military-related coverage. SOURCE: KCMU/Urban Institute analysis of March 2007 CPS.

9. Medicaid and SCHIP Enrollment of Children, FY 1998 – FY 2005
Millions of Children
SOURCE: Kaiser Commission on Medicaid and the Uninsured and Urban Institute analysis of HCFA-2082, MSIS, and SEDS data, 2007.

10. Percentage of Children Without Health Insurance, By Poverty Level, 1997-2005
23%
Children below
200% of poverty
21%
14% 6%
Children above
200% of poverty 5% 5%
* Survey method change in 2005 affects comparison with earlier years slightly. Children less than 18 years old.
Source: L. Ku, “Medicaid: Improving Health, Saving Lives,” Center on Budget and Policy Priorities analysis of National Health Interview Survey data, August 2005.

11. Children’s Eligibility for Medicaid/SCHIP by Income, July 2007NH VT WA ME MT ND MN MA OR NY ID SD WI MI RI WY CT PA IA NJ NE OH IN NV IL IL WV DE UT VA CO MD CA KS MO KY NC DC TN OK SC AR AZ NM AL GA MS TX LA
IMPLEMENTED:
<200%: AK, ID, MT,OR, ND, NE, OK, SC, WI (9)
200%: AL, AZ, AR, CO, DE, FL, IL, IA, IN, KS, KY, LA, ME, MI, MS, NV, NC, OH, SD, TX, UT, VA, WY (23)
%: CA, GA, NM, NY, RI, TN, WA, WV (8)
>250%: CT, DC, HI, MD, MA, MN, MO, NH, NJ, PA, VT (11)
CHANGES: TN, DC, PA AK FL HI
< 200% FPL (9 states)
200% FPL (23 states)
% FPL (8 states)
> 250% FPL (11 states including DC)
*The Federal Poverty Line (FPL) for a family of three in 2006 is $16,600 per year.
**IL uses state only funds to cover children above 200% FPL
SOURCE: Based on a national survey conducted by the Center on
Budget and Policy Priorities for KCMU, 2006.

12. Medicaid Eligibility for Working Parents,
by Income, July 2006 NH VT WA ME MT ND MN MA OR NY ID SD WI MI RI WY CT PA IA IL NJ NE OH IN NV WV DE UT VA CO MD CA KS MO KY NC DC TN OK SC AR AZ NM AL GA MS TX LA AK FL HI
≥100% FPL* (16 states including DC)
National Average = 67% FPL
50% - 99% FPL (21 states)
< 50% FPL (14 states)
* Federal Poverty Level (FPL) refers here to HHS Poverty Guidelines, $16,600 for a family of three in 2006.
SOURCE: Center on Budget and Policy Priorities for KCMU, 2005

13. The Uninsured by Income and Eligibility for Public Coverage, 2004
Not Eligible, 300%+ FPL 15%
Not Eligible, 300%+ FPL 21%
Eligible 14%
Not Eligible, <300% FPL
11%
Eligible 74%
Not Eligible, <300% FPL 65%
Children Million Uninsured
Adults Million Uninsured
*The Federal Poverty Line (FPL) for a family of three in 2004 is $15,067 per year
SOURCE: Urban Institute analysis of 2005 CPS for KCMU.

14. Renewed State Interest in Expanding Coverage
Fiscal outlook improving for states
Increased tax revenues
Growth in Medicaid spending leveling off
42 states have plans to expand health coverage
States using Medicaid to support financing and enrollment
Improving Medicaid and SCHIP coverage, particularly for children
Universal coverage plans passed in 3 states, proposed in 11 others
Need to address growing uninsured population
Driven by declining rates of employer-sponsored insurance
Exacerbated by rising health care costs
Desire to improve the quality and efficiency of current health care system

15. Comprehensive Health Care Reform*
States Moving Toward
Comprehensive Health Care Reform* WA VT ME MN OR NY MA WI PA CT IL CO CA KS NM
Enacted Universal Coverage (3 states)
Proposed Universal Coverage (12 states)
*as of December 1, 2007

16. Role of Medicare and Medicaid in State Reform
Medicare covers the elderly and some disabled
Medicaid provides:
coverage through expanded eligibility and increased outreach
a financing vehicle through redirected DSH funds
a source of federal assistance through matching funds for increased coverage and provider payments

17. Key Elements of the Massachusetts Health Care Reform Plan
Individual Mandate
Mandate enforced through tax filings
Employer Assessment
Employers with >10 employees that don’t offer coverage must pay $295 per employee per year
Subsidized Coverage
Sliding scale subsidies for individuals <300% FPL
Full subsidies for those <100% FPL
The Connector
Links consumers & small employers to insurance
Establishes affordability standards and certifies insurance products
Medicaid Expansion to Children <300% FPL

18. Proposed Coverage for Uninsured under Massachusetts Reform
Medicaid Expansion
17%
92,500 residents
Subsidized coverage
38%
207,500 residents
Remain Uninsured
6%,
35,000 residents
Private Insurance
39%
215,000 residents
Total Uninsured – 550,000
Source: Massachusetts Senate

19. Massachusetts Reform Plan Revenues SFY 2008
Employer Assessment
Other
Hospital Assessment
Insurance Surcharge
Federal Medicaid Matching Payments
State General Funds
Total Revenues = $1.725 Billion
Source: Massachusetts Executive Office of Administration and Finance

20. Massachusetts Reform Implementation Update
MassHealth (Public Program Expansion)
From end of June 2006 to July 2007, MassHealth enrollment increased by nearly 56,000
Commonwealth Care (Subsidized Connector)
Commonwealth Care plans (offered by Medicaid managed care plans) became available October 2006
As of October 2007, 127,000 have enrolled in Commonwealth Care
Vast majority of enrollees (80%) have incomes below 150% FPL
Commonwealth Choice (Unsubsidized Connector)
Plans from six carriers approved, available May 1, 2007
Plans became available to small businesses October 1, 2007
Enrollment to date more limited

21. National Interest in Health Care Also Rising
Percent naming HEALTH CARE as one of the top two issues they’d most like to hear presidential candidates talk about, by political party self-identification:
Source: Kaiser Health Tracking Poll: Election 2008

22. Presidential Candidates Differ in Approach to Health Care Reform
Democrats generally favor:
universal coverage
strengthening the private employer-based system
expanding the role of existing public programs for low-income
purchasing pools and insurance market reforms
coverage mandates on employers and individuals
financing by rolling back tax breaks for wealthiest Americans
Republicans generally favor:
tax incentives for the purchase of insurance
expanding the individual insurance market
limiting the role of public programs; more state flexibility
consumer-directed plans such as HSAs
deregulation of the insurance market

23. Hillary Clinton Barack Obama John Edwards Rudy Giuliani Mitt Romney
John McCain
Plan Announced:
9/17/07
5/29/07
2/18/07
7/31/07
8/24/07
10/11/07
Individual Mandates
For Children Only
Employer Mandates
Public Program Expansion
New Insurance Pooling Mechanism
Premium Subsidies
Insurance Market Regulation
More
Less
Change Tax Treatment of Insurance
Caps for >$250,000
Encourage Consumer-Directed Care

24. Public Programs and Health Reform
Medicaid provides a coverage base for low-income
Coverage could be extended to more children, parents, and other adults
Medicaid funding used to finance coverage expansions
Medicaid helps promote state reform efforts
SCHIP reauthorization debate raises issues for public role
Income eligibility for public coverage
Scope of coverage and the role of private plans
Public programs vs. tax credits for coverage
Medicare as a vehicle for expanded coverage
Single-payer proposals modeled after Medicare
Buy-in options for early retirees